SUBSTANCE ABUSE SERVICES APPLICATION

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1 DIVISION OF ALCOHOLISM AND SUBSTANCE ABUSE LICENSING AND CERTIFICATION SUBSTANCE ABUSE SERVICES APPLICATION ALCOHOLISM AND OTHER DRUG DEPENDENCY TREATMENT/INTERVENTION LICENSE OR MEDICAID CERTIFICATION This application is for: (check only one) Initial Services Additional Services PART I: GENERAL INFORMATION - Required of All Initial Applicants for each Facility ORGANIZATION INFORMATION Complete Legal Name: Official Legal Address: Suite, Floor, Room, P.O. Box No.: City: State: Zip Code: Telephone: ( ) County: Fax: ( ) Address: PLEASE SPECIFY: Government Entity: Federal State County Local FEIN: Corporation (Specify Type)- For Profit Not for Profit Partnership Association Sole Proprietor Other ATTACH PROOF FROM THE SECRETARY OF STATE THAT THE ABOVE ORGANIZATION IS AUTHORIZED TO DO BUSINESS IN ILLINOIS AND IS IN GOOD STANDING, COPY OF ARTICLES OF INCORPORATION, BYLAWS, LETTER OF AGREEMENT OF PARTNERSHIP, ETC., AS APPLICABLE. ATTACH A COMPLETED SCHEDULE A - OWNERSHIP DISCLOSURE, FOR EACH OWNER OR CONTROLLING PARTY OF THE ORGANIZATION OR CORPORATION (UNLESS SUCH PERSON OWNS LESS THAN 5% STOCK IN THE CORPORATION). FACILITY - Required of All Initial Applicants and Additional Service Applicants Name: Address: Suite, Floor, Room, P.O. Box No.: City: State: Zip Code: Telephone: ( ) County: Fax: ( ) Address: IMPORTANT NOTICE: The Department of Human Services is requesting voluntary disclosure of information that is necessary to accomplish the statutory purposes as provided in Ill. Rev. Stat., ch. 20 ILCS 301 and 77 Ill. Adm. Code Non-disclosure of this information may prevent this form from being processed. Form approved by State Forms Management Center. The Department does not discriminate in its activities in compliance with the Americans with Disabilities Act of 1990 and with the Civil Rights Act. Should you need assistance regarding this application, please contact (312) (01/04)

2 AUTHORIZED ORGANIZATION REPRESENTATIVE - Required of All Initial Applicants and Additional Service Applicants Name: Address: Suite, Floor, Room, P.O. Box No.: City: State: Zip Code: Title: Telephone: ( ) MANAGEMENT - Required of All Applicants Specify the names of all board members and the name, address and phone number of the Chairman of the Board. LEVELS OF CARE, TYPES OF SERVICES AND POPULATIONS SERVED - Required of All Initial Applicants or Additional Service Applicants Please specify the levels of care and/or types of services provided at the facility or those services, which will be added to an existing license. Alcoholism and Substance Abuse Treatment Level I (Outpatient) Level II (Intensive Outpatient) Level III Subacute (Inpatient Residential) Level III (Residential Extended Care) Level IV Detoxification Ambulatory or Clinically Managed Detoxification Medically Monitored Detoxification Medically Managed (Level IV) Methadone used as adjunct to treatment Alcoholism and Substance Abuse Intervention DUI Evaluation Recovery Home DUI Risk Education Designated Program Specify fee charged for DUI Evaluation: $ DUI Risk Education: $ 2

3 Medicaid Certification Specify DASA or IDPH License Number: Level I Level II Level III Subacute (Residential Rehabilitation) Level III Subacute (Day Treatment) Level III (Medically Monitored Detoxification) Level III (Medically Monitored Detoxification Hospital Subacute Setting) Is the facility JCAHO accredited? Yes No Is the facility CARF accredited? Yes No Is the facility COA accredited? Yes No PART II: FACILITY REQUIREMENTS Applicable to all substance abuse treatment, DUI evaluation, DUI risk education, Recovery Home, and designated program services license applicants. ATTACH A COPY OF A SCHEDULE C - STATEMENT OF COMPLIANCE AND LIFE SAFETY INSPECTION REPORT COMPLETED BY AN ARCHITECT FOR THE FACILITY SPECIFIED IN THIS APPLICATION. PART III: REQUIREMENTS Policies and Procedures Operating Manual for all services. Professional Staff Requirements - Applicable to all license applicants except Recovery Homes and all Medicaid certification applicants not licensed by the Department. SUBPART C REQUIREMENTS ALL LICENSES Section Service Termination/Record Retention Professional Staff Qualifications Staff Training Requirements Personnel Requirements and Procedures Quality Improvement Service Fees Confidentiality Patient Information Confidentiality HIV Antibody/AIDS Status Patient Rights Patient/Client Records Emergency Patient Care Referral Procedure Incident and Significant Incident Reporting 3

4 SUBPART D: REQUIREMENTS TREATMENT LICENSES SUBSTANCE ABUSE TREATMENT- Required of all applicants for substance abuse treatment and Medicaid certification who do not have a Department license or any applicant who is proposing to add treatment service to an already existing intervention license. Section Levels of Care - (If Applying for Treatment License) Court Mandated Treatment Detoxification - (As Applicable) Group Treatment Patient Education Recreational Activities - (As Applicable) Medical Services Infectious Disease Control Assessment for Patient Placement Assessment for Treatment Planning Treatment Plans Continued Stay Review Progress Notes and Documentation of Service Delivery Continuing Recovery Planning and Discharge SUBPART E: REQUIREMENTS INTERVENTION LICENSES INTERVENTION LICENSES - Required of all applicants for substance abuse intervention services, as applicable, and for any applicant with a treatment license proposing to add any of the following intervention services. Section DUI Evaluation - (As Applicable) DUI Risk Education Designated Program Recovery Homes PART IV: MEDICAL DIRECTOR - Applicable to all applicants licensed by the Department for substance abuse treatment and all Medicaid certification applicants not licensed by the Department. ATTACH A COMPLETED SCHEDULE E FOR THE FACILITY S MEDICAL DIRECTOR AND ANY OTHER PHYSICIAN WHO WILL PROVIDE SUBSTANCE ABUSE TREATMENT SERVICES. PART V: MEDICAID CERTIFICATION ONLY Please attach: documentation that the facility or parent organization has been licensed as applicable for at least two years. documentation demonstrating two years of experience in providing quality substance abuse services of the kind for which certification is being requested and for the type of population which will be served. evidence of the need within the community for the type of services to be provided for which certification is sought, including but not limited to: 4

5 a description of the geographic area served by the program; a description of the population, including the size of the population, including the age groups, the number of population in need of service; a description of the current treatment service(s) provided and the number estimated to have Medicaid coverage; a description of how the addition of Medicaid certification will increase the availability of treatment for those who cannot access it; and a description of how the organization works with the treatment system to assure that individuals receive services. a description of the organization that will be operating the program. documentation that the organization is fiscally solvent. a description of the facility that will be utilized. a description of the program and the clients it serves. utilizing the attached estimated client population grid, provide a projection of the total number of Medicaid clients to be served each month, the average length of stay anticipated and the estimated average per client cost of treatment. a schedule of specific day, times and places services will be provided. provide the number and type of people served during the previous two years in the program for which certification is sought and a description of the clients served. (Demographics, gender, drug of choice, Medicaid eligibility, income level and etc.). a copy of the two most recent utilization review reports. copy of the organization s measurable outcome evaluation process for the past two years and statistics on the program s client outcomes, i.e., statistical data on clients who complete treatment and data from client satisfaction questionnaires. for any applicant currently funded by the Department, attach evidence of compliance with all applicable Department audit requirements as specified in Administrative Code 507. documentation that the facility is JCAHO accredited, if application is being made by a hospital based program. PART VI: INTERVENTION LICENSES - Required of all applicants for substance abuse intervention services, as applicable, and for any applicant with a treatment license proposing to add any of the following intervention services. DUI EVALUATION AND RISK EDUCATION ONLY Please list any foreign language services offered at the facility: 5

6 RECOVERY HOMES ONLY Please attach: a description of the structured alcohol and drug free environment that offers regularly scheduled peer-led or community gatherings (self-help groups, etc.) held a minimum of five days per week. copies of written linkage agreements with substance abuse providers. a description of the referral network to be utilized by residents for any necessary medical, mental health, vocational or employment resources. a copy of a budget which specifies monthly operating expenses and demonstrates sufficient income to meet these expenses plus emergency reserve documenting access to a minimum sum equivalent to the total of two months of operating expenses. documentation of compliance with all applicable zoning and local building ordinances and the provisions specified in Chapter 20 (Lodging or Rooming Houses) of the National Fire ProtectionAssociation s (NFPA) Life Safety Code of 1994 for any building housing 16 or fewer residents and with the provisions specified in Chapter 17 (Existing Hotels and Dormitories) of the NFPA Life Safety Code of 1994 for any building housing 17 or more residents. documentation of fire, hazard, liability and other insurance coverages appropriate to the administration of a recovery home. documentation of employment of at least one full-time Recovery Home Operator who: 1) either: A) holds clinical certification from IAODAPCA or receive such certification within two years after the date of employment; or B) has a minimum of 300 hours of education in the field of substance abuse, 50% of which shall have been under clinical supervision of a professional staff as defined in Section ; and 2) has a minimum of 2,000 hours of work experience or 4,000 hours of volunteer experience in the field of substance abuse of which 1,500 hours shall have been in direct clinical services; and 3) has two years of continuous sobriety; and 4) has provided three letters of recommendation from substance abuse professional staff as defined in Section ; and 5) has provided a signed and dated acceptance of the Code of Ethics as established by the Illinois Association of Residential Extended Care Programs (IARECP). Attach documentation of employment of at least one Recovery Home Manager who: 1) holds certification as a National Certified Recovery Specialist (NCRS) as specified by the Association of Halfway House Alcoholism Programs of North America, Inc., 680 Stewart Avenue, St. Paul, Minnesota or will receive such certification within two years after the date of employment; or 2) holds certification from IAODAPCA or will receive such certification within two years after the date of employment; or 3) has one year of continuous sobriety and 60 hours of substance abuse education and training verified by transcripts, certificates of attendance and/or third party signed statements. 6

7 Estimated Client Population Grid Initial Medicaid Certification Facility Name: Estimated Client Population Grid WEEKLY CAPACITY ESTIMATE Service Total Program Capacity Clients in Program Weekly Number of Medicaid Clients Sessions (Individual) Sessions (Group) Days of Service Number of Non-Medicaid Clients Sessions (Individual) Sessions (Group) Days of Service Average Cost of Treatment Per Person Outpatient (Level I) Outpatient (Level I) Intensive Outpatient (Level II) Intensive Outpatient (Level II) Residential Rehabilitation (Level III) Day Treatment (Level III) Day Treatment (Level III) Medically Monitored Detoxification 7

8 PART VII: APPLICANT AFFIRMATION - Required of All Applicants The application must be signed by: at least two corporate officers vested with authority to act on behalf of the corporation, or; if applicant is a partnership or association, by all partners or associates; and by the Chairman of the Board of Directors. Use additional pages as necessary. By signature below applicant hereby certifies and affirms that there are no current citations for local ordinance violations; that any previous citations have been corrected to the satisfaction of all applicable authorities; and that the premises are in compliance with all applicable state and local codes. By signature below applicant acknowledges the right of the Department to verify the data supplied in this license application and consents to such inquiries as might be required. It is understood that, confidential information provided in this application or obtained during the course of any inquiry will be used only for the purposes collected and be maintained confidential by the Department, and not re-released except as allowed by law. Any information provided in the application which the applicant believes to be confidential/proprietary information or trade secrets should be clearly marked as such or applicant waives its right to claim confidentiality regarding such. By signature below applicant certifies and affirms that none of the applicant s owners, operators or managers have had a federal registration to distribute or dispense methadone, suspended or revoked or had any governmental license relating to the operation of the facility suspended or revoked, or been convicted within the previous two (2) years in any court of law of operating a motor vehicle while under the influence of alcohol or any drug. By signature below applicant certifies and affirms that the content of this application and attached schedules, affirmations and materials are true and correct. By signature below applicant certifies and affirms that it is in compliance with all applicable provisions of state and federal constitutions, laws, regulations, court rules and judicial orders, including but not limited to: a) The Illinois Human Rights Act, [775 ILCS 5]; b) The Americans with Disabilities Act of 1990, (42 USC 12101) and the regulations and guidelines; c) The Environmental Barriers Act [410 ILCS 25] and The Illinois Accessibility Code (71 Ill. Adm. Code 400); d) The Age Discrimination Act of 1975; and e) The 1991 Civil Rights Act. Signature Date Signature Date Name (Type/Print) Name (Type/Print) Date Date SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY OF, (Seal) 8 NOTARY PUBLIC/STATE OF ILLINOIS

9 PART XI: LICENSE FEE INFORMATION A separate application is required for each facility. A license application fee of $200 is required for each facility. NOTE: There is no fee required for Medicaid certification. No fee of any type is required from any unit of local, state or federal government. Application fees are due upon application for each facility license. Application fees are not refundable. Payment shall be made by check or money order made payable to the Department of Human Services Payment shall not be in the form of U.S. currency, foreign currency, or stamps. A separate check or money order shall be submitted with each application. PART XII: MAILING INFORMATION Please submit the completed application and fee, if applicable, to: Illinois Department of Human Services Division of Alcoholism and Substance Abuse Bureau of Licensing and Certification 401 South Clinton Street, Second Floor Chicago, Illinois

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